Patterns of Perioperative Hormone Therapy for Gender-Affirming Surgery.

INTRODUCTION: There is no consensus regarding perioperative hormone replacement therapy (HRT) for gender-affirming surgery (GAS). Common concerns for continuing perioperative HRT included risk of deep vein thrombosis (DVT) or hematoma. However, discontinuing HRT is not risk free and may cause mood swing or increased anxiety. Our study aimed to investigate current patterns of HRT before GAS worldwide. METHODS: The first stage of Delphi technique was implemented by sending a 27-item survey to all surgeons (total n = 150; 94 plastic surgeon, 35 urologist, and 21 gynecologists) of the World Professional Association for Transgender Health who perform GAS. Survey themes included the hormone type, duration, and usage of DVT prophylaxis. RESULTS: Overall survey response rate was 34% (total n = 51; 8 urologists, 35 plastic surgeons, and 8 gynecologists). The majority of surgeons are US-based (n = 39, 76%). The most common HRTs are in injection form (n = 28, 55%). The majority of surgeons do not stop HRT before GAS and do provide DVT prophylaxis to all patients <1 week after GAS. The most common procedure that surgeons discontinue HRT is feminizing bottom surgery (43%). For surgeons who discontinue HRT before GAS, there is a wide variation on discontinuation schedule. CONCLUSIONS: There is considerable variation in perioperative HRT patterns for GAS. Further research is needed to develop a data-driven consensus guideline to provide high quality of care for transgender and nonbinary patients.

Multidimensional Assessment of Patient-Reported Outcomes After Gender-Affirming Surgeries Using a Validated Instrument.

INTRODUCTION: Limited literatures used validated instruments to evaluate patient-reported outcomes (PROs) for transgender and gender-diverse population undergoing gender-affirming surgeries (GASs). This study aimed to evaluate PROs using a newly validated psychometric instrument, Vanderbilt Mini Patient-Reported Outcome Measures-Gender (VMP-G). METHODS: Vanderbilt Mini Patient-Reported Outcome Measures-Gender assesses 4 scales: quality of life, self-concept, satisfaction, and gender dysphoria. Scores range from 20 to 100, with higher scores representing superior PROs. Descriptive analysis was performed, and outcomes were compared in different races/ethnicities, gender identities, age, types of GAS, and time. Patients seeking GAS at Vanderbilt University Medical Center from October 11, 2021, to October 11, 2022, were included. Data were collected anonymously via the Research Electronic Data Capture survey tool at preoperative or postoperative clinic visits. RESULTS: A total of 207 patients completed VMP-G. Average age was 31.8 years (SD, ±11.5 years). Fifty-three percent of patients were postoperative GAS. In bivariate and linear regression analyses, postoperative patients scored higher on all scales compared with preoperative patients ( P < 0.001). After adjustment, postoperative patients scored 12.5 higher on VMP-G compared with preoperative patients ( P < 0.01). In subset analyses, GAS was associated with improved PROs in White, non-White, binary, and nonbinary and patients younger than 21 years ( P < 0.05). After GAS, patients younger than 21 years reported similar outcomes, compared with patients older than 21 years ( P > 0.05). No PROs differences were reported between patients who underwent top versus bottom surgery ( P = 0.2). Postoperative patients reported low rates of regret (2.8%). Scores on the VMP-G were sustained even 1 year after GAS. Each month after GAS was associated with a score improvement of 0.02 in the gender dysphoria domain after adjusting for patient demographics ( P = 0.02). CONCLUSIONS: Using a validated GAS-specific measure, we found that surgery sustainably improves patients' self-reported outcomes including gender dysphoria.

The Paramedian Forehead Flap: A Retrospective Clinical Model for Understanding the Connection Between Supraorbital and Supratrochlear Nerve Pathology and Headaches.

Background: In the later stages of a paramedian forehead flap (PMFF) surgery, the supratrochlear (STN) and branches of the supraorbital nerve (SON) are transected during flap inset above the supraorbital rim. This can lead to either a nerve release if the compression point was previously distal to the transection point or a new nerve compression through neuroma or scar tissue formation. We inferred that PMFF could be a model for understanding the correlation between STN/SON pathology and migraines headaches (MH). We hypothesized that patients undergoing PMFF would experience either a change in severity or an onset of a new headache (HA) or MH. Methods: One hundred ninety-nine patients who underwent a PMFF at a tertiary medical centre were identified and contacted by phone. Patients were asked about the presence of MH or HA before and after the procedure. If a patient reported a perioperative history of MH/HA, their pre- and postoperative MH/HA characteristics were recorded. Results: Of the 199 patients contacted, 74 reported no perioperative HA/MH history and 14 reported a perioperative history of HA/MH. Of these 14 patients, 5 had stable HA/MH pre- and post-surgery, and 9 reported a change in HA/MH post-surgery. In this subset of 9 patients, 3 reported change in HA/MH quality post-surgery, 1 reported HA/MH resolution post-surgery, and 5 reported new onset HA/MH post-surgery. Conclusion: Sixty-four percent of patients with perioperative HA/MH experienced a change in headache quality following surgery. These results suggest a potential connection between SON and STN pathology and HA/MH pathophysiology; further work is warranted.

Historique: Dans les dernières phases de l'opération du lambeau frontal paramédian (LFPM), le nerf supratrochléaire (NST) et les rameaux du nerf supraorbital (NSO) sont sectionnés pour installer le lambeau au-dessus de l'arcade sourcilière. Cette intervention peut libérer le nerf si le point de compression se trouvait auparavant dans la partie distale de l'incision ou provoquer une nouvelle compression nerveuse par la formation d'un névrome ou de tissu cicatriciel. Les chercheurs ont présumé que le LFPM pouvait servir de modèle pour comprendre la corrélation entre la pathologie du NST ou du NSO et les migraines. Les chercheurs ont postulé que les patients qui se font greffer un LFPM présenteraient soit un changement de la gravité de leurs migraines ou de leurs céphalées ou de nouvelles migraines ou céphalées. Méthodologie: Les chercheurs ont communiqué par téléphone avec 191 patients qui se sont fait greffer un LFPM dans un centre de soins tertiaires. Ils leur ont demandé s'ils souffraient de migraines ou de céphalées avant et après l'intervention. Si le patient déclarait des antécédents périopératoires de migraines ou de céphalées, les chercheurs en consignaient les caractéristiques. Résultats: Des 199 patients, 74 n'ont déclaré aucun antécédent de migraines ou de céphalées, mais 14 ont signalé une histoire périopératoire de ces symptômes. De ces 14 patients, cinq présentaient une migraine ou une céphalée avant et après l'opération et neuf, un changement à ces manifestations. Dans ce sous-groupe de neuf patients, trois ont déclaré un changement de la qualité des migraines et des céphalées après l'opération, un en a signalé la résolution après l'opération et cinq, l'apparition après l'opération. Conclusion: Au total, 64% des patients ayant des migraines et des céphalées ont ressenti un changement à la qualité de leurs symptômes après l'opération. Ces résultats laissent croire à un lien potentiel entre la pathologie du NSO et du NST et la physiopathologie des migraines et des céphalées. D'autres travaux s'imposent sur le sujet.